Essential Health Benefit Preventive Drug List

2021

AFFORDABLE CARE ACT

In addition to a healthy lifestyle, preventive prescription drugs are important in helping people avoid many types of illnesses and complications from illnesses. The Patient Protection and Affordable Care Act (PPACA) requires that most health plans cover certain preventive drugs at 100% and are not subject to a deductible.

Important facts about this benefit

• Please refer to your plan documents information specific to your preventive coverage. Quantity limits, step therapy, prior authorizations and other coverage limitations may apply.

• This list is updated annually on a calendar year basis.

• Unless otherwise noted, only generic drugs will be covered.

Security Health Plan provides coverage of the following ACA preventive drug categories at no out-of-pocket cost, subject to any plan limitations. A prescription from your doctor is required for preventive drugs including over-the-counter drugs. This list is not all-inclusive and is subject to change.

You can view your Summary of Benefits and Certificate of Coverage or Policy online when you log

into your My Security Health Plan account. If you don’t have an account go to

www.securityhealth.org/registration.

Aspirin (81, 325 mg )

Clenpiq Osmoprep Prepopik

Golytely Peg-3350 and Electrolytes Suprep

Moviprep Plenvu

Raloxifene Tamoxifen

Diaphragms Spermicides (Otc) Vaginal sponge

Cervical cap Female condoms

Balcoltra 0.1-0.02 mg Natazia 3-2-1 Taytulla 1 mg-20

Lo Loestrin Fe 1 mg-10 Slynd 4 mg

Econtra Ez 1.5 mg My Choice 1.5 mg Opcicon One-Step 1.5 mg

Econtra One-Step 1.5 mg My Way 1.5 mg Option 2 1.5 mg

Ella 30 mg New Day 1.5 mg Take Action 1.5 mg

Levonorgestrel 1.5 mg

Generic oral hormonal contraceptives

Afirmelle 0.1-0.02 mg Hailey 24 Fe 1 mg-20 Norethin-Eth Estra-Ferrous Fum 0.8-25

Aftera 1.5 mg Hailey Fe 1.5-30 Norethin-Eth Estra-Ferrous Fum 1 mg-20

Altavera 0.15-0.03 Hailey Fe 1 mg-20 Norethin-Eth Estra-Ferrous Fum 1 mg-20

Alyacen 1 mg-35 mcg Heather 0.35 mg Norgestimate-Ethinyl Estradiol 0.25-0.035

Alyacen 7 Days X 3 Incassia 0.35 mg Norgestimate-Ethinyl Estradiol

Amethia 150-30 Introvale 0.15-0.03 Norgestimate-Ethinyl Estradiol Lo

Amethia Lo 100-20 Isibloom 0.15-0.03 Norlyda 0.35 mg

Amethyst 90-20 mcg Jaimiess 150-30 Nortrel 0.5-0.035

Apri 0.15-0.03 Jasmiel 0.02-3 Nortrel 1 mg-35 mcg

Aranelle 7-9-5 Jencycla 0.35 mg Nortrel

Ashlyna 150-30 Jolessa 0.15-0.03 Ocella 0.03 mg-3 mg

Aubra 0.1-0.02 mg Juleber 0.15-0.03 Ogestrel 0.5 mg-50

Aubra Eq 0.1-0.02 mg Junel Fe 1.5-30 Orsythia 0.1-0.02 mg

Aurovela 24 Fe 1 mg-20 Junel Fe 1 mg-20 Philith 0.4-0.035

Aurovela Fe 1.5-30 Junel Fe 24 1 mg-20 Pimtrea 21-5

Aurovela Fe 1 mg-20 Kaitlib Fe 0.8-25 Pirmella 1 mg-35 mcg

Aviane 0.1-0.02 mg Kalliga 0.15-0.03 Pirmella

Ayuna 0.15-0.03 Kariva 21-5 Portia 0.15-0.03

Azurette 21-5 Kelnor 1-35 1 mg-35 mcg Previfem 0.25-0.035

Balziva 0.4-0.035 Kelnor 1-50 1 mg-50 mcg Reclipsen 0.15-0.03

Bekyree 21-5 Kurvelo 0.15-0.03 Rivelsa 0.15 mg

Blisovi 24 Fe 1 mg-20 Larin 24 Fe 1 mg-20 Setlakin 0.15-0.03

Blisovi Fe 1.5-30 Larin Fe 1.5-30 Sharobel 0.35 mg

Blisovi Fe 1 mg-20 Larin Fe 1 mg-20 Simliya 21-5

Briellyn 0.4-0.035 Larissia 0.1-0.02 mg Simpesse 150-30

Camila 0.35 mg Layolis Fe 0.8-25 Sprintec 0.25-0.035

Camrese 150-30 Leena 7-9-5 Sronyx 0.1-0.02 mg

Camrese Lo 100-20 Lessina 0.1-0.02 mg Syeda 0.03 mg-3 mg

Caziant 7 Days X 3 Levonest 6-5-10 Tarina 24 Fe 1 mg-20

Charlotte 24 Fe 1 mg-20 Levonorgestrel-Eth Estradiol 0.1-0.02 mg Tarina Fe 1-20 Eq 1 mg-20

ACA EHB preventive drug list

Bowel preparation products

Aspirin

Breast cancer prevention drugs

Prevention of preeclampsia during pregnancy, cardiovascular disease and colorectal cancer

Preparation for colonoscopy screening; colonoscopies screen for colon and rectal cancers

Brand name drugs are only covered if a generic alternative is not available; drugs are restricted to members between 50 and 75 years of age; quantity limit of 2 per year.

Barrier contraceptives

Brand hormonal contraceptives

Prevention of breast cancer in high-risk women

Emergency contraceptives

Prevention of pregnancy

Contraceptives

Brand name drugs are only covered if a generic alternative is not available.

Chateal 0.15-0.03 Levonorgestrel-Eth Estradiol 0.15-0.03 Tarina Fe 1 mg-20

Chateal Eq 0.15-0.03 Levonorgestrel-Eth Estradiol 0.15-0.03 Tilia Fe 5-7-9-7

Cryselle 0.3-0.03 mg Levonorgestrel-Eth Estradiol 2006-05-10 Tri Femynor

Cyclafem 1 mg-35 mcg Levonorgestrel-Eth Estradiol 6-5-10 Tri-Estarylla

Cyclafem 7 Days X 3 Levonorgestrel-Eth Estradiol 90-20 mcg Tri-Legest Fe 5-7-9-7

Cyred 0.15-0.03 Levonorg-Eth Estrad Eth Estrad 0.15 mg Tri-Linyah

Cyred Eq 0.15-0.03 Levonorg-Eth Estrad Eth Estrad 100-20 Tri-Lo-Estarylla

Dasetta 1 mg-35 mcg Levonorg-Eth Estrad Eth Estrad 150-30 Tri-Lo-Marzia

Dasetta 7 Days X 3 Levora-28 0.15-0.03 Tri-Lo-Mili

Daysee 150-30 Lillow 0.15-0.03 Tri-Lo-Sprintec

Deblitane 0.35 mg Lojaimiess 100-20 Tri-Mili

Desogestrel-Ethinyl Estradiol 0.15-0.03 Loryna 0.02-3 Tri-Previfem

Desogestr-Eth Estrad Eth Estra 21-5 Low-Ogestrel 0.3-0.03 mg Tri-Sprintec

Drospirenone-Eth Estra-Levomef 3-0.02 Lo-Zumandimine 0.02-3 Trivora-28 6-5-10

Drospirenone-Eth Estra-Levomef 3-0.03 Lutera 0.1-0.02 mg Tri-Vylibra

Drospirenone-Ethinyl Estradiol 0.02-3 Lyza 0.35 mg Tri-Vylibra Lo

Drospirenone-Ethinyl Estradiol 0.03 mg-3 mg Marlissa 0.15-0.03 Tulana 0.35 mg

Elinest 0.3-0.03 mg Melodetta 24 Fe 1 mg-20 Tydemy 3-0.03

Emoquette 0.15-0.03 Mibelas 24 Fe 1 mg-20 Velivet

Enpresse 6-5-10 Microgestin Fe 1.5-30 Vienva 0.1-0.02 mg

Enskyce 0.15-0.03 Microgestin Fe 1 mg-20 Viorele 21-5

Errin 0.35 mg Mili 0.25-0.035 Volnea 21-5

Estarylla 0.25-0.035 Mono-Linyah 0.25-0.035 Vyfemla 0.4-0.035

Ethynodiol-Ethinyl Estradiol 1 mg-35 mcg Necon 0.5-0.035 Vylibra 0.25-0.035

Ethynodiol-Ethinyl Estradiol 1 mg-50 mcg Nikki 0.02-3 Wera 0.5-0.035

Falmina 0.1-0.02 mg Nora-Be 0.35 mg Wymzya Fe 0.4-35

Fayosim 0.15 mg Norethindrone 0.35 mg Zarah 0.03 mg-3 mg

Femynor 0.25-0.035 Norethindrone-Eth Estradiol-Fe 1.5-30 Zovia 1-35E 1 mg-35 mcg

Gianvi 0.02-3 Norethin-Eth Estra-Ferrous Fum 0.4-35 Zumandimine 0.03 mg-3 mg

Other contraceptives

Depo-Provera (Quantity limit of 1 per 90 days) Liletta Paragard T 380-A

Nexplanon (Quantity limit of 1 per year) Mirena Skyla

Ring hormonal contraceptives

Annovera Etonogestrel/Ethinyl Estradiol Eluryng

Transdermal contraceptives

Xulane

Fluoride (chewable tablets, oral drops)

Folic Acid (400, 800 mcg)

Iron (oral drops)

Truvada 200-300 mg

(Brand Truvada until generic is available)

Emtricitabine 200 mg Tenofovir Disoproxil Fumara 300 mg

Bupropion HCL SR Nicotine Inhaler (Nicotrol®) - Covered only after a trial

of nicotine transdermal patch, gum, or lozenge.

Nicotine Spray (Nicotrol NS®) - Covered only after a trial

of nicotine transdermal patch, gum, or lozenge.

Chantix Nicotine Lozenge Nicotine Transdermal Patch

Nicotine Gum

Generic oral hormonal contraceptives (continued)

Iron supplements

Folic acid supplements

Fluoride supplements

Prevention of dental cavities if water source is deficient in fluoride

Prevention of birth defects

Restricted to members between 6 months and 6 years of age.

Restricted to members between 6 and 12 months of age.

Brand drugs are only covered if a generic alternative is unavailable; drugs are restricted to members age 18 and over; quantity limit applies.

Prevention of iron deficiency anemia

PrEP (Pre-exposure prophylaxis)

Smoking cessation

Prevention of health problems associated with tobacco use

Prevention of HIV infection

Atorvastatin (10, 20 mg ) Lovastatin (10, 20, 40 mg ) Rosuvastatin (5, 10 mg )

Fluvastatin (20, 40, ER 80 mg ) Pravastatin (10, 20, 40, 80 mg ) Simvastatin (5, 10, 20, 40 mg )

Influenza vaccines Measles, mumps, rubella (Age 18 or older) Tetanus, diptheria (Age 18 or older)

Human papillomavirus (Age 9-26 years) Meningococcal (Age 10-25 years) Varicella (Age 18 or older)

Hepatitis A (Age 18 or older) Pneumococcal (Age 65 or older) Zoster vaccine, Live (Zostavax®) (Age 60 or older)

Hepatitis B (Age 18 or older) Tetanus, diptheria, pertussis (Age 18 or older) Zoster vaccine, recombinant (Shingrix®) (Age 50 or

older)

Vaccines for travel

Cholera Rabies Yellow Fever

Japanese encephalitis Typhiod

Prevention of infectious diseases

Vaccines

Restricted to members between the ages of 40 and 75; quantity limited to statin dosages at low-to-moderate intensity; no concurrent use of secondary prevention drugs (e.g.,

Aggrenox (aspirin/dipyridamole), Plavix (clopidogrel), dipyridamole, nitroglycerin (oral, sublingual, transdermal, translingual), Effient (prasugrel), Brilinta (ticagrelor),

ticlopidine, Zonitivity).

Prevention of cardiovascular disease events

Statins (low to moderate intensity)

Discrimination is against the law Security Health Plan of Wisconsin, Inc., complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, disability, age, sex, gender identity, sexual orientation or health status in the administration of the plan, including enrollment and benefit determinations. Security Health Plan does not exclude people or treat them differently because of race, color, national origin, disability, age, sex, gender identity, sexual orientation or health status.

Security Health Plan: Provides free aids and services to people with disabilities to communicate effectively with us,

such as: o Qualified sign language interpreters o Written information in other formats (large print, audio, accessible electronic formats,

other formats) Provides free language services to people whose primary language is not English, such as:

o Qualified interpreters o Information written in other languages

If you need these services, contact Customer Service at 1-800-472-2363 (TTY 711). If you believe that Security Health Plan has failed to provide these services or discriminated in another way on the basis of race, color, national origin, disability, age, sex, gender identity, sexual orientation or health status, you can file a grievance with:

Security Health Plan Attn: Grievances 1515 North Saint Joseph Avenue Marshfield, WI 54449-8000

Phone: 715-221-9596 (TTY 711) Fax: 715-221-9424 Email: shp.appeals.grievance@securityhealth.org

You can file a grievance in person or by mail, fax or email. If you need help filing a grievance, Security Health Plan can help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

U.S. Department of Health and Human Services 200 Independence Avenue SW. Room 509F, HHH Building Washington, DC 20201

Phone: 1–800–368–1019 or 800–537–7697 (TDD) Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

ATTENTION: If you speak a language other than English, language assistance services, free of charge, are available to you. Call 1-800-472-2363 (TTY 711).

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Hmoob (Hmong) LUS CEEV: Yog tias koj hais lus Hmoob, cov kev pab txog lus, muaj kev pab dawb rau koj. Hu rau 1-800-472-2363 (TTY 711).

繁繁體體中中文文 (Chinese) 注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電 1-800-472-2363 (TTY 711)。

Deutsch (German) ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: 1-800-472-2363 (TTY 711).

(Arabic) العربية)رقم هاتف الصم 3632-274-008-1 ملحوظة: إذا كنت تتحدث اذكر اللغة، فإن خدمات المساعدة اللغوية تتوافر لك بالمجان. اتصل برقم

(.117 والبكم

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Deitsch (Pennsylvania Dutch) Wann du Deitsch schwetzscht, kannscht du mitaus Koschte ebber gricke, ass dihr helft mit die englisch Schprooch. Ruf selli Nummer uff: 1-800-472-2363 (TTY 711).

ພພາາສສາາລລາາວວ (Lao) ໂປດຊາບ: ຖ້າວ່າ ທ່ານເວົ້າພາສາ ລາວ, ການບໍລິການຊ່ວຍເຫຼືອດ້ານພາສາ, ໂດຍບໍ່ເສັຽຄ່າ, ແມ່ນມີ

ພ້ອມໃຫ້ທ່ານ. ໂທຣ 1-800-472-2363 (TTY 711).

Français (French) ATTENTION : Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le 1-800-472-2363 (ATS 711).

Polski (Polish) UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej. Zadzwoń pod numer 1-800-472-2363 (TTY 711).

हह िंिंददीी (Hindi) ध्यान दें: यदद आप ह िंदी बोलते हैं तो आपके ललए मुफ्त में भाषा सहायता सेवाए ंउपलब्ध हैं। 1-800-472-2363 (TTY 711) पर कॉल करें।

Shqip (Albanian) KUJDES: Nëse flitni shqip, për ju ka në dispozicion shërbime të asistencës gjuhësore, pa pagesë. Telefononi në 1-800-472-2363 (TTY 711).

Tagalog (Filipino) PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa 1-800-472-2363 (TTY 711).

Oroomiffa (Oromo/Somalia) XIYYEEFFANNAA: Afaan dubbattu Oroomiffa, tajaajila gargaarsa afaanii, kanfaltiidhaan ala, ni argama. Bilbilaa 1-800-472-2363 (TTY 711).

Large print – If you require materials in large print, please call 1-800-472-2363 (TTY 711).

注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電 1-800-472-2363 (TTY 711)。

Deutsch (German) ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: 1-800-472-2363 (TTY 711).

(Arabic) العربية)رقم هاتف الصم 3632-274-008-1 ملحوظة: إذا كنت تتحدث اذكر اللغة، فإن خدمات المساعدة اللغوية تتوافر لك بالمجان. اتصل برقم

(.117 والبكم

Русский (Russian) ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните 1-800-472-2363 (телетайп 711).

한한국국어어 (Korean)

주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다. 1-800-472-2363 (TTY 711) 번으로 전화해 주십시오.

Tiếng Việt (Vietnamese) CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số 1-800-472-2363 (TTY 711).

Deitsch (Pennsylvania Dutch) Wann du Deitsch schwetzscht, kannscht du mitaus Koschte ebber gricke, ass dihr helft mit die englisch Schprooch. Ruf selli Nummer uff: 1-800-472-2363 (TTY 711).

ພພາາສສາາລລາາວວ (Lao) ໂປດຊາບ: ຖ້າວ່າ ທ່ານເວົ້າພາສາ ລາວ, ການບໍລິການຊ່ວຍເຫຼືອດ້ານພາສາ, ໂດຍບໍ່ເສັຽຄ່າ, ແມ່ນມີ

ພ້ອມໃຫ້ທ່ານ. ໂທຣ 1-800-472-2363 (TTY 711).

Français (French) ATTENTION : Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le 1-800-472-2363 (ATS 711).

Polski (Polish) UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej. Zadzwoń pod numer 1-800-472-2363 (TTY 711).

हह िंिंददीी (Hindi) ध्यान दें: यदद आप ह िंदी बोलते हैं तो आपके ललए मुफ्त में भाषा सहायता सेवाए ंउपलब्ध हैं। 1-800-472-2363 (TTY 711) पर कॉल करें।

Shqip (Albanian) KUJDES: Nëse flitni shqip, për ju ka në dispozicion shërbime të asistencës gjuhësore, pa pagesë. Telefononi në 1-800-472-2363 (TTY 711).

Tagalog (Filipino) PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa 1-800-472-2363 (TTY 711).

Oroomiffa (Oromo/Somalia) XIYYEEFFANNAA: Afaan dubbattu Oroomiffa, tajaajila gargaarsa afaanii, kanfaltiidhaan ala, ni argama. Bilbilaa 1-800-472-2363 (TTY 711).

Large print – If you require materials in large print, please call 1-800-472-2363 (TTY 711).

25210-000

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1-877-873-5611 715-221-9604 TTY 711 Fax 715-221-9989

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